Occlusione intestinale su briglia in paziente con pregressa diagnosi di sindrome di Ogilv

A case of a 72-year-old man with abdominal pain and ileus is reported. Previous surgery for Ogilvie?s syndrome had been performed. Despite conservative therapy, the occlusive symptoms worsen. Therefore the patient was submitted to surgery. At laparotomy two abdominal adhesions were found and sectioned. The differential diagnosis between mechanical ileus and pseudo-obstruction for neuro-mechanics dissociation (Ogilvie?s syndrome) is difficult, particularly in patients with neurodegenerative diseases

[Gangrene of Meckel's diverticulum in strangulated left inguinal hernia].

We report a case of a 57-year-old woman admitted for abdominal pain and a not reducible mass in left inguino-abdominal region. With a diagnosis of strangulated inguinal hernia, the patient underwent urgent surgery. The surgical exploration showed a gangrenous intestinal loop with a Meckel's necrotic diverticulum. A small bowel resection (20 cm) was performed. The post-operative course was uneventful. This seems the first case reported in the literature of woman with a Meckel's diverticulum involved in a strangulated left inguinal hernia

Clinical effects of laparotomy with perioperative continuous peritoneal lavage and postoperative hemofiltration in patients with severe acute pancreatitis

<p>Abstract</p> <p>Background</p> <p>The elevated serum and peritoneal cytokine concentrations responsible for the systemic response syndrome (SIRS) and multiorgan failure in patients with severe acute pancreatitis lead to high morbidity and mortality rates. Prompted by reports underlining the importance of reducing circulating inflammatory mediators in severe acute pancreatitis, we designed this study to evaluate the efficiency of laparotomy followed by continuous perioperative peritoneal lavage combined with postoperative continuous venovenous diahemofiltration (CVVDH) in managing critically ill patients refractory to intensive care therapy. As the major clinical outcome variables we measured morbidity, mortality and changes in the Acute Physiology and Chronic Health Evaluation (APACHE II) score and cytokine concentrations in serum and peritoneal lavage fluid over time.</p> <p>Methods</p> <p>From a consecutive group of 23 patients hospitalized for acute pancreatitis, we studied 6 patients all with Apache II scores ≥19, who underwent emergency surgery for acute complications (5 for an abdominal compartment syndrome and 1 for septic shock) followed by continuous perioperative peritoneal lavage and postoperative CVVDH. CVVDH was started within 12 hours after surgery and maintained for at least 72 hours, until the multiorgan dysfunction syndrome improved. Samples were collected from serum, peritoneal lavage fluid and CVVDH dialysate for cytokine assay. Apache II scores were measured daily and their association with cytokine levels was assessed.</p> <p>Results</p> <p>All six patients tolerated CVVDH well, and the procedure lasted a mean 6 days (range, 3-12). Five patients survived and one died of Acinetobacter infection after surgery (mortality rate 16.6%). The mean APACHE II score was ≥ 19 (range 19-22) before laparotomy and decreased significantly during peritoneal lavage and postoperative CVVDH (P = 0.013 by matched-pairs Students <it>t</it>-test). The decrease in cytokine concentrations in serum and lavage fluid was associated with the decrease in APACHE II scores and high interleukin 6 (IL-6) and tumor necrosis factor (TNF) concentrations in the hemofiltrate.</p> <p>Conclusion</p> <p>In critically ill patients with abdominal compartment syndrome, septic shock or high APACHE II scores related to severe acute pancreatitis, combining emergency laparotomy with continuous perioperative peritoneal lavage followed by postoperative CVVHD effectively reduces the local and systemic cytokines responsible for multiorgan dysfunction syndrome thus improving patients' outcome.</p

Inflammatory myoglandular polyp of the cecum: case report and review of literature

<p>Abstract</p> <p>Background</p> <p>Inflammatory myoglandular polyp (IMGP) is a rare non-neoplastic polyp of the large bowel, commonly with a distal localization (rectosigmoid), obscure in its pathogenesis. Up till now, 60 cases of IMGP have been described in the literature, but none located in the cecum.</p> <p>Case presentation</p> <p>We report a case of a 53-year-old man who was admitted to our hospital for further evaluation of positive fecal occult blood test associated to anemia. A colonoscopy identified a red, sessile, lobulated polyp of the cecum, 4.2 cm in diameter, partially ulcerated. The histological examination of the biopsy revealed the presence of inflammatory granulation tissue with lymphocytic and eosinophil infiltration associated to a fibrous stroma: it was diagnosed as inflammatory fibroid polyp. Considering the polyp's features (absence of a peduncle and size) that could increase the risk of a polypectomy, a surgical resection was performed. Histological examination of the specimen revealed inflammatory granulation tissue in the lamina propria, hyperplastic glands with cystic dilatations, proliferation of smooth muscle and multiple erosions on the polyp surface: this polyp was finally diagnosed as IMGP. There was also another little polyp next to the ileocecal valve, not revealed at the colonoscopy, 0.8 cm in diameter, diagnosed as tubulovillous adenoma with low grade dysplasia.</p> <p>Conclusions</p> <p>This is the first case of IMGP of the cecum. It is a benign lesion of unknown pathogenesis and must be considered different from other non-neoplastic polyps of the large bowel such as inflammatory cap polyps (ICP), inflammatory cloacogenic polyps, juvenile polyps (JP), inflammatory fibroid polyps (IFP), polyps secondary to mucosal prolapse syndrome (MPS), polypoid prolapsing mucosal folds of diverticular disease. When symptomatic, IMGP should be removed endoscopically, whereas surgical resection is reserved only in selected patients as in our case.</p

Identificazione, inquadramento e terapia endoscopica delle neoplasie precoci del colon-retto

N/AN/

Difficult biliary stones in the elderly. Endoscopic retrograde cholangiography. A single surgical tertiary centre experience with follow-up

Background: Pancreaticobiliary diseases and choledocholithiasis are common in elderly patients. Endoscopic treatment of biliary stones represents a well-established mini-invasive technique. However, limited data are available regarding the treatment of 'difficult' biliary stones, especially in the elderly population. The aim of our study is to evaluate the efficacy and safety of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients ≥85 years of age with complex biliary stones.Materials and Methods: From January 2015 to January 2017, data from ERCP procedures performed for complex biliary stones were retrospectively collected. The patients were divided into two groups based on their age: Group A - aged 85 years or older (n = 110) and Group B - aged 65 years or younger (n = 62). Demographic data, success, complications and recurrence rates for both groups were reported.Results: Chronic comorbidities (86.3% vs. 24.2%; P &lt; 0.001) and use of antithrombotic drugs (48.2% vs. 19.3%; P &lt; 0.001) were more frequent in the elderly. The technical success rate (95.4% vs. 96.7%; P &gt; 0.6) and complication rate (8.2% vs. 13%; P &gt; 0.2) were not statistically different among the two groups. Periampullary diverticula (PAD) were observed more frequently in Group A (38.1% vs. 17.7%; P &lt; 0.006). More patients from Group B underwent cholecystectomy during the same admission (8.2% vs. 42.3%; P &lt; 0.001). The recurrence rate was not different among the groups (7.6% vs. 5%; P &gt; 0.5). PAD was identified as the risk factor for recurrence (P &lt; 0.02).Conclusion: ERCP in the elderly was found to be a safe procedure, carrying a high degree of success for the treatment of difficult biliary stones

Early ‘shallow’ needle-knife papillotomy and guidewire cannulation: an effective and safe approach to difficult papilla

Introduction: Needle-knife sphincterotomy (NKS), known as ‘precut’, is used worldwide to facilitate access to the common bile duct when standard cannulation has failed. This procedure is considered hazardous because it is burdened with high procedural related complications (bleeding and perforation). Its right timing is still debated. In this study we report our results using a modified precut approach, early shallow needle-knife papillotomy (eSNKP) coupled with guidewire cannulation in case of difficult papilla. We evaluated its safety and effectiveness. Methods: From 2012 to 2014, 1034 patients underwent therapeutic ERCP. A total of 138 of them presented difficult papilla and were treated with eSNKP performed after 5 failed attempts of standard guidewire cannulation. Deep biliary cannulation rate was recorded, as well as intraoperative and postoperative complication rate. Results: Successful biliary deep cannulation was achieved in 132/138 patients (95.7%) by means of eSNKP. In 6 patients (4.3%), cannulation failed even after eSNKP. ERCP was newly performed 72 hours later with successful and immediate guidewire biliary cannulation. Overall morbidity was 10.1% (14/138). No perforation occurred. Minor bleeding occurred in 4/138 cases (2.9%) and 10/138 patients (7.2%) developed mild pancreatitis. Conclusion: In case of difficult papilla, eSNKP followed by guidewire cannulation increases the successful deep biliary cannulation with low rate of complications

Double inferior vena cava does not complicate para-aortic nodal dissection for the treatment of pancreatic carcinoma

Duplication of the inferior vena cava (IVC) involves large veins on both sides of the aorta that join anteriorly at the level of the renal arteries to become the suprarenal IVC. We report CT scan and intraoperative images of a patient with duplication of the IVC who underwent pancreaticoduodenectomy with para-aortic lymphadenectomy for carcinoma of the pancreatic head: nodal dissection along the left caval vein was not carried out. The anatomical background of the lymphatic flow to the para-aortic lymph nodes and the theoretic basis for lymph node dissection of the para-aortic area in cases of double IVC are highlighted. Lymphadenectomy along the left caval vein is not necessary in patients with double IVC who undergo pancreaticoduodenectomy with extended lymphadenectomy for carcinoma of the pancreatic head in the absence of preoperative appearance of para-aortic disease

La prevenzione del dolore e dell’emorragia post-operatoria nella PPH (Procedure for Prolapse and Hemorrhoids) e nella STARR (Stapled Trans-Anal Rectal Resection). Risultati su una serie di 261 pazienti

e intra- e post-operatorie precoci (entro la pima settimana) rappresentano la più frequente complicanza nella emorroidectomia con PPH (Procedure for Prolapse and Hemorrhoids) e nella resezione circonferenziale del prolasso rettale con STARR (Stapled Trans Anal Rectal Resection). Durante l’esecuzione di PPH e STARR abbiamo impiegato un gel emostatico a base di trombina (FloSeal®) per controllare il sanguinamento intra-operatorio e ridurre quello post-operatorio evitando l’apposizione di punti emostatici sulla linea di sutura. Riportiamo i primi risultati di uno studio retrospettivo su 197 pazienti sottoposti a PPH e 64 sottoposti a STARR. In 44 PPH (22,4%) ed in 27 STARR (42,2%) è stato utilizzato il gel emostatico. Non si sono verificati sanguinamenti post-operatori significativi nei pazienti trattati con FloSeal®, contro l’ 1,3% e il 2,7% di emorragie rispettivamente in PPH e STARR nei pazienti trattati senza gel emostatico. Il dolore post-operatorio è stato meno severo nei pazienti trattati con FloSeal®, senza tuttavia una differenza statisticamente significativa. I dati ottenuti devono essere considerati preliminari e da confermare in studi prospettici randomizzati condotti su più ampie casistiche